Pelvic Organ Prolapse: What It Is and How to Manage It

Your gynecologist or urogynecologist diagnosed you with pelvic organ prolapse. What does this mean?

Pelvic organ prolapse is defined by Haylen et al. as “the descent of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus (cervix), or the apex of the vagina (vaginal vault or cuff scar after hysterectomy).”

We can think about structures “relaxing” back into the front of the vaginal wall (anterior wall) or falling forward into the back of the vaginal canal (posterior wall).

What are the types of pelvic organ prolapse?

The type of prolapse is named for the organs that “fall down” and cause the vaginal walls to bulge and descend.

Cystocele, urethrocele, and urethrocystocele

The bladder (left) sinks into the anterior wall of the vagina.

Also in the front, a woman might be diagnosed with a urethrocele (urethra) or urethrocystocele (both urethra and bladder desend back toward the vaginal wall).

Symptoms of a cystocele

Since a cystocele is an architectural change where the bladder has relaxed into the anterior (front) vaginal wall, your urinary function might be altered. You might feel a bulge, or feel like there is something stuck in your vagina. You may also experience sexual dissatisfaction.

Some women will experience a slower trickle during urination, which results in a longer stream duration. Sometimes it might be hard to start the flow of urine or be able to stop midstream. (Note: stopping midstream is confusing for the bladder and should not be practiced as a way of strengthening your pelvic floor.)

Some women experience a urine stream that starts and stops a few times while voiding. This can lead to incomplete bladder emptying or urinary retention. This can also lead to increased urinary frequency because your bladder has not emptied it’s capacity, and the woman will feel the first urge to urinate sooner than normal. Cystocele may also lead to urinary incontinence.

STRATEGY

Lean forward and back while you are sitting on the toilet to urinate to change the angle of the urethra to get a more complete void.

Rectocele and enterocele

The rectum (right) falls into the back of the vaginal wall. vaginal wall, which is called a rectocele.

The rectum can descend forward into the posterior vaginal wall, which is called a rectocele.

Also affecting the back vaginal wall is a enterocele, which is when the small bowel herniates thru the pouch of Douglas and falls into the posterior vaginal wall.

Symptoms of a rectocele

Women who have been diagnosed with a rectocele will often feel vaginal pressure or discomfort as the rectum is pressing into the back of the vaginal wall. You might feel a bulge, or feel like there is something stuck in your vagina. You might also feel sexual dissatisfaction.

Because of this relaxation of the rectum forward, you may start to have incomplete emptying during bowel movements. This might lead to more straining, which increases your risk of making the rectocele worse.

STRATEGY

Try a splinting technique with bowel movements. Press your fingers up and back at the perineal body (skin between the vagina and the anus) during a bowel movement. Alternatively, insert your finger into your vaginal canal, pressing back toward the rectum. This creates more structural support and stability at the vaginal wall during bowel movements.

And, don’t forget to optimize the anorectal angle by using a stool to elevate your feet while having a bowel movement!

Uterine prolapse

The uterus (left) descends down into or out of the vaginal canal.

Uterine prolapse occurs when the uterus descends down into or out of the vaginal canal.

Symptoms of a uterine prolapse

If your uterus starts to descend out of it’s preferred anatomical position, it shifts downwards in the vaginal canal. When the uterus is starting to make contact with underwear, it can create abrasions and you might experience blood-stained discharge, possibly accompanied by pus. You might feel a bulge, or feel like there is something stuck in your vagina. You might also experience sexual dissatisfaction.

Women who have a uterine prolapse will often experience difficulty with complete bowel or bladder emptying. You might also experience low back pain increases as the day goes on because of the pull of gravity. This usually shows up as a decreased tolerance to prolonged standing.

STRATEGY

If possible, lay down around noon and before dinner for a few minutes in a supported bridge pose, or even flat with your legs up the wall. This will counteract the force of gravity and unload your organs.

Rectal prolapse

The rectum (right) drops down.

Different than a rectocele, where the rectum falls forward into the back vaginal wall, men and women can experience a rectal prolapse. The rectum, the termination of the large intestine, bulges down to or out of the anus.

What makes you more likely to develop a prolapse?

The following experiences or conditions can increase your risk of prolapse:

vaginal delivery: potential tearing and soft tissue damage

chronic constipation and straining

excessive coughing due to chronic obstructive airway disease: puts increased intra-abdominal pressure on the system

prior pelvic surgery

estrogen deficiency

connective tissue hypermobility disorders, like Ehlers-Danlos

How can I prevent prolapse?

Manage constipation

Constipation is defined by less than three bowel movements a week with stool consistency that is dry, hard, and difficult or painful to pass.

Constipation can be caused by:

surgery

poor diet and hydration

pelvic floor muscle incoordination

lack of activity

side effects from medicine

motility issues

inflammation

functional disorders

As with any medical condition it is important that you are properly diagnosed so you know what the proper treatment is for you. If you and your provider suspect diet might play a role in your symptoms, being properly hydrated, increasing fiber intake, and avoiding irritants may provide relief.

Your pelvic floor muscles might be tight or uncoordinated, causing bowel movements to be sluggish, incomplete, or painful. Some techniques to try are elevating your feet on a Squatty Potty (or stool), working with the pelvic floor muscles (lengthen or strengthen), and abdominal massage. The Bristol stool scale is a self-assessment tool you can use to communicate with your provider about stool consistency. Ideally you want to be a type 3 or 4 on the Bristol stool scale.

When constipation has a mechanical cause, musculoskeletal and myofascial restrictions play into the dysfunction. Yoga can help support healthy gut function through slow, mindful movements that increase flexibility and integrate breath with the movement.

How do breath work and inner reflection help? Yoga helps control the release of compounds in your body: serotonin (the feel-good neurotransmitter) and cortisol (the stress hormone). The majority of serotonin is produced in your gut. Strengthening the parasympathetic nervous system response via breath work, meditation, and gentle movement can help you balance the levels cortisol and serotonin in your body.

Notice your sitting posture

Studies demonstrate a relationship between sitting posture and prolapse. Sitting in a slumped position with our pelvis tucked under decreases the natural curve in our back and weakens the pelvic floor muscles. Prevent or decrease severity of prolapse by optimizing your sitting posture throughout the day.

STRATEGY

If you get engrossed in your task at the computer and find yourself crumpled over, set a timer to go off every 15 minutes to remind yourself to lengthen your spine. Better yet, stand for 30 seconds, do some sort of movement, and sit back down.

How does a physical therapist treat pelvic organ prolapse?

As pelvic health specialists, we look at the entire body:

Is there hip weakness contributing to the prolapse symptoms?

How is the core firing?

Do you have an old ankle sprain that didn’t get rehabbed fully?

How are you breathing?

How do your musculoskeletal system look in standing and sitting?

How are your body mechanics when you pick up your child or groceries?

Is the pelvic floor able to contract well, have good endurance, and fully relax?

After being diagnosed and treated by your gynecologist or urogynecologist, who might offer assistive devices like pessaries, there is so much more you are able to do, unless you are an immediate surgical candidate. We are here to help!

Yoga for pelvic organ prolapse

As a physical therapist I prescribe home exercise programs that increase pelvic floor and core strength for women with prolapse. If you are interested in yoga, check out Optimizing Bladder Control: Strengthening the Pelvic Floor. The content is similar to a traditional physical therapy program with the additional focus of the breath and specific yoga postures.

Just like you would monitor when exercising with diastasis recti abdominus, you want to be sure that the load is not too much for the system. Be sure you are not bearing down if you are practicing a side plank or regular plank. Sometimes modifying with your knees down is a way to still activate your core but still have enough control in the pelvis.

Please note, sometimes women who have surgery for a pelvic organ prolapse will need to have a revision, so it is wise to practice these tips even if you have had surgery!

I’d love to hear from you! Let me know if these tips are useful or have something to share in the comments below!